5 take-aways from latest congressional hearing on Medicare fraud

On Wednesday, representatives of the Department of Health and Human Services (HHS), the Centers for Medicare and Medicaid Services (CMS) and the Government Accountability Office (GAO) were once again called upon by House republicans to explain what is being done to combat waste, fraud and abuse in Medicare. Their responses give a glimpse into the agencies current priorities, especially as they affect healthcare providers.

The “Medicare Program Integrity: Screening Out Errors, Fraud, and Abuse” hearing took place in front of the U.S. House of Representatives Energy and Commerce Committee’s subcommittee on Oversight and Investigations. Testifying were Shantanu Agrawal, M.D., deputy administrator and director of the CMS Center for Program Integrity; Gary Cantrell, deputy inspector general for Investigations of the HHS Office of Inspector General (OIG); Kathleen M. King, director of Health Care for the GAO. Cut through the competing proposals and a certain amount of finger pointing, and several key take-aways for healthcare providers become apparent:

1. Enrolling as a Medicare provider could become tougher, but not immediately so. There was broad agreement that efforts to stop illegitimate providers from enrolling in Medicare in the first place needed to be enhanced. However, CMS is still up against a very de-centralized system for even basic tracking of individuals criminal convictions, license to practice and state certification. This will not change soon. The only notable immediate change is that some individuals with an ownership interest in a business with a high fraud risk, such  durable medical equipment, prosthetics, orthotics and supplies providers and home health agencies, are now finger printed as part of the enrollment process.
2. Count on the wack-a-mole approach to fraud prevention to continue as the administration representatives told the panel that they plan to concentrate efforts on the areas where there seems to be the highest incidence of fraud. Currently, these priority areas include durable medical equipment, home health, outpatient clinics and pharmacies, stated Gary Cantrell of the OIG.
3. Providers frustrated by computer programs that erroneously flag legitimate claims as possibly fraudulent may need to get used to it. CMS’s Fraud Prevention System program that applies analytics to claim data and sends leads to its Zone Program Integrity Contractors is now being tested for use with the Medicare Administrative Contractors too, said Dr. Agrawal of CMS.
4. Medicare Advantage plan claims may become more prone to audits. Cantrell of the OIG reiterated his agency’s position that CMS should mandate that private insurers report fraud and abuse in the Medicare Advantage health plans. Currently it is only voluntary and CMS has resisted dictating requiring insurers to show that they are tough on fraud and abuse in Medicare Advantage.
5. Some additional safeguards to prevent patient identity theft could be coming. Recommendations made to the House representatives included taking patient social security numbers off Medicare ID cards and mandating that all electronic health record systems have audit logs that can’t be deleted by users.

All testimoney and opening comments are available on the Oversight and Investigations Subcommittee website.